Disaster management plans need to be evaluated regularly and improved.

1. St. Mary Medical Center conducts an annual review of its risks, hazards, andpotential emergencies as defined in the HVA:

Annually, prior to the end of the first quarter, St. Mary Medical Center conducts an annual evaluation and review of the HVA to ascertain the following:

2. The hospital conducts an annual review of the objectives and scope if its EOP:

On an annual basis or as required the Emergency Management Committee and Environment of Care Committee will conduct a review of the effectiveness of emergency management planning activities. The annual review will include the following processes:

The Objectives of the EOP will be evaluated as follows:The intent of the objectives will be reviewed to determine if still relevant and applicable, and if change or modification is required.

The Scope of the EOP will be evaluated as follows:Planning activities will be reviewed to determine if modifications are required due to changes within the facility, its structure, the patient population served, community planning partners or other factors that may have an impact on disaster response to emergencies.

The HVA will be reviewed to determine if risks, preparedness and mitigation strategies have changed or altered to lower or increase overall probability of defined risks.

The annual evaluation process is documented in an annual review report.

3. The hospital conducts an annual review of its inventory process:

On an annual basis or as required, the facilities EOC/Disaster Committee will conduct a review of the effectiveness of emergency management planning activities. The inventory of organizational assets will be reviewed to determine if resources and assets relating to emergency preparedness have changed.

4. The annual emergency management planning reviews are forwarded to senior hospital leadership for review.The leadership review includes those leaders with responsibility for organization wide strategic planning and budgets.

Identified potential emergencies that may inflict the hospital are still valid.

An identified potential emergency that may inflict the community is still valid.